A now 5-week-old term infant male presents to the emergency room with post-prandial projectile non-bilious and non-bloody emesis for two weeks. The mother states that the baby has only been having two or three wet diapers per day over the past week (previously had 6-8 wet diapers per day). On review of the vitals, temperature is 37.4 C, heart rate is 124, blood pressure is 69/36, respirations are 34/min, oxygen saturation is 100% on room air. On exam, the patient is alert with a flat fontanel and normal skin turgor with capillary refill of 2 seconds. He has a palpable "olive" in the epigastrium. Ultrasound demonstrates a thickened and elongated pylorus.
Which of the following best describes this patient's metabolic status
a. Hypokalemic, hypochloremic metabolic alkalosis with acuduria
b. Normal electrolytes and urinalysis
c. Hyperkalemic, hyperchloremic metabolic alkalosis with acuduria
d. Hypokalemic, hypochloremic metabolic alkalosis with alkaline urine
e. Hypokalemic, hypochloremic metabolic acidosis with aciduria
A previously healthy full-term female infant, now 4 weeks old, is brought to her primary pediatrician because of a 3-day history of postprandial projectile vomiting of nonbilious emesis. She had previously been taking 3 ounces of milk-based formula feeds every 3 hours without difficulty and had been gaining weight on previous well-child examinations. She typically has 6 wet diapers and 3 bowel movements daily; she has not had fever or rash.
On physical examination, the patient is 9.6 lb (4.35 kg); at her last appointment 2 weeks ago, she was was 9.4 lb (4.25 kg). Her temperature is 98.8°F (37.1°C), pulse is 115/min and regular, respirations are 26/min, and blood pressure is 62/38 mm Hg. Oxygen saturation is 100% on room air. The fontanel is full, skin turgor is good, and mucous membranes are moist. The extremities are warm and well perfused, and capillary refill is brisk. No heart murmur is heard. The lungs are clear to auscultation. Abdominal examination discloses no distention, and a palpable "olive" is noted in the epigastrium. There are no hernias or masses.
Further questioning of the parents will most likely elicit which of the following descriptions of the infant's behavior after each episode of emesis?
b. Irritable, arching, and in pain
d. Irritable, crying, and hungry
e. Alert and comfortable
A 9-week-old female infant is brought to the emergency department because of postprandial projectile vomiting. Her mother reports the patient has not had a bowel movement for 2 days and has had only one wet diaper during the past 24 hours. The emesis has been nonbilious and nonbloody. The infant was delivered at 37 weeks' gestation following an otherwise uncomplicated pregnancy.
On physical examination, the patient weighs 7.3 lb (3.3 kg); she weighed 7.9 lb (3.6 kg) at birth. Her temperature is 99.0°F (37.2°C), pulse is 144/min, respirations are 48/min, blood pressure is 60/34 mm Hg, and oxygen saturation is 100% on room air. The patient is somnolent and has a sunken fontanel. Skin turgor is diminished, and capillary refill is delayed. An "olive" is palpated in the epigastrium. Results of a basic metabolic panel show serum sodium of 118 mEq/L, serum potassium of 2.8 mEq/L, serum chloride of 59 mEq/L, and serum bicarbonate 49 mEq/L; blood urea nitrogen of 30 mg/dL, serum creatinine of 1.2 mg/dL, and plasma glucose of 56 mg/dL. Upper gastrointestinal examination reveals a narrow, elongated pyloric channel consistent with a "string sign."
When did this patent's symptoms likely begin?
4 hours ago
8 weeks ago
4 weeks ago
3 days ago
A 38 year old man developed severe, right lower quadrant abdominal pain 6 hours prior to his emergency department presentation. Prior to this, he was feeling well.
He has poor appetite, nausea, vomiting, diarrhea, and reports a subjective fever at home, though he did not check his temperature.
He denies dysuria, melena, hematochezia, or a history of similar symptoms. Yesterday, he reports he felt perfectly well.
He has no significant past medical, surgical or family history. He takes no medications or supplements daily and has no known drug allergies.
On physical examination, which of the following would most support your clinical diagnosis:
a. Feeling Hungry
b. Right upper quadrant tenderness, worse with inspiration
c. Observing that the patient lies with his legs extended and resists flexion
d. Normal bowel sounds
e. Reproduction of his right lower quadrant abdominal pain with internal rotation of his flexed right hip
72-year-old man with chronic kidney failure secondary to type 2 diabetes mellitus is evaluated for a 3-week history of worsening fatigue and joint pain. He currently requires 3 hemodialysis sessions weekly. He adheres to his current medication regimen of atenolol, lisinopril, a phosphate binder, metformin, atorvastatin, omeprazole, and neurontin.
On physical examination, temperature is 98.6°F (37.0°C), pulse is 89/min, respirations are 14/min, and blood pressure is 140/86 mm Hg. Examination of the right arm shows a well-functioning arteriovenous fistula. The remainder of the examination is unremarkable.
Serum calcium 11.2 mg/dL (normal: 8.9-10.1 mg/dL)
Serum phosphorus 4.7 mg/dL (normal: 2.5-4.5 mg/dL)
Serum intact parathyroid hormone 68 pg/mL (normal: 10-55 pg/mL)
PART A: Which of the following is the most likely cause of the hypercalcemia?
a. Primary hyperparathyroidism
b. Secondary hyperparathyroidism
c. Tertiary hyperparathyroidism
d. Quaternary hyperparathyroidism
e. Parathyroid carcinoma
PART B: What would be the best initial treatment of his hypercalcemia?
a. Increase frequency of hemodialysis
b. Schedule focused parathyroidectomy
c. Schedule 3.5-gland parathyroidectomy
d. Start cinacalcet
e. Increase dose of phosphate binder
42-year-old man is referred to a gastroenterologist for peptic ulcer disease that has been refractory to medical therapy. An endoscopic evaluation 3 weeks ago showed multiple duodenal ulcers. Eight years ago, he underwent transphenoidal resection of a pituitary adenoma. He has passed 2 ureteral stones during the past 2 years. His current medications are omeprazole and a daily multivitamin.
On physical examination, temperature is 98.6°F (37.0°C), pulse is 72/min, respirations are 14/min, and blood pressure is 124/72 mm Hg. No thyroid masses are palpated.
Serum gastrin 432 pg/mL (normal: <100 pg/mL)
Serum calcium 14.8 mg/dL (normal: 8.9-10.1 mg/dL)
Which of the following is the most likely underlying diagnosis?
MEN syndrome, type I
MEN syndrome, type IIB
MEN syndrome, type III
MEN syndrome, type IIC
MEN syndrome, type IIA
A 71-year-old man is evaluated for lightheadedness and weakness of the right arm since he awoke this morning. He reports trying to reach for his watch, "but my arm didn't respond to my brain's command." He dismissed the incident and went back to sleep. Two hours later, he awakened and was able to get out of bed without difficulty. At this time, his arm felt normal. He has no history of similar episodes. The patient, who has a 30-pack-year smoking history, has hypertension and hypercholesterolemia, and he sustained a myocardial infarction 6 years ago. He underwent coronary stent placement at that time. Current medications are aspirin, lisinopril, atorvastatin, and occasional ibuprofen for muscle pain.
On physical examination, the patient is not feeling lightheaded. temperature is 98.6°F (37.0°C), pulse is 90/min and regular, respirations are 22/min, and blood pressure is 140/76 mm Hg. No bruits are heard. Muscle strength is 4 bilaterally. Neurological examination reveals no evidence of motor or sensory deficits.
A -Which of the following is the most likely diagnosis?
a. Intracranial cerebral aneurysm
b. Transient ischemic attack
c. Hemorrhagic stroke
d. Intracranial brain tumor
e. Ischemic stroke
B- Which of the following is the best next step in management?
b. Magnetic resonance imaging (MRI) of the brain
c. Admission for observation and anticoagulant therapy
d. Carotid ultrasound
e. Magnetic resonance angiography (MRA) of the neck
C- Which of the following guidelines will be most helpful for management of this condition?
a. North American Symptomatic Carotid Endarterectomy Trial (NASCET)
b. Carotid Revascularization Endarterectomy vs Stent Trial (CREST)
c. European Carotid Surgery Trial (ECST)
d. Asymptomatic Carotid Atherosclerosis Study (ACAS)
e. Asymptomatic Carotid Surgery Trail (ACST)
A 48- year-old woman comes to the emergency department because of increasing abdominal pain, chills, and fever for the past 36 hours. Six days ago, she underwent an uncomplicated laparoscopic colectomy with primary anastomosis for recurrent diverticulitis, and she was discharged on the morning of postoperative day 4. At that time, she was passing flatus and tolerating a soft diet. Later that morning, she started to feel ill. She has not had a bowel movement since discharge.
On physical examination, her temperature is 101.8°F (38.8°C), pulse is 110/min and regular, respirations are 18/min, and blood pressure is 110/70 mm Hg. The chest is clear to auscultation, and no murmurs are heard. There is moderate tenderness to palpation over the lower abdomen.
Which of the following is the most likely cause for the change in her medical condition?
a. Intra-abdominal abscess
b. Missed intraoperative ureteral injury
c. Postoperative ileus
d. Clostridium difficile colitis
e. Recurrent diverticulitis
A 72-year-old woman presents to the emergency department with a 4-hour history of intense abdominal pain preceded by 2 days of vague left lower quadrant pain and nausea. She has no history of similar episodes. Her medical history is remarkable for atrial fibrillation, hypertension, and type 2 diabetes mellitus. Her current medications are amiodarone, losartan, hydrochlorothiazide, and enalapril. She has no history of previous surgeries.
On physical examination, temperature is 101.0°F (38.4°C), pulse is 125/min and irregular, respirations are 20/min, and blood pressure is 132/86 mm Hg. Pulse oximetry shows an oxygen saturation of 99%. The abdomen is exquisitely tender to palpation of the left and right lower quadrants; a mass is appreciated in the left lower quadrant, and palpation elicits abdominal guarding. Intravenous fluids are begun, and the patient is instructed to receive nothing by mouth. Results of laboratory studies are pending.
Which of the following laboratory results would necessitate the greatest change in the subsequent management of this patient's condition?
a. Hemoglobin of 10.2 g/dL (normal: 12-15 g/dL)
b. Leukocyte count: 14,000/mm3 (normal: 4000-11,000/mm3)
c. C-reactive protein of 42 mg/L (normal: <5 mg/L)
d. Urinalysis showing 10 RBCs, 2 WBCs/hpf, leukocyte esterase positive, nitrite positive
e. Serum creatinine of 2.3 mg/dL (normal: <1.4 mg/dL)